Swallowtail Place

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated Inadequate.

This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. This is because, they did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. We found due to a lack of management oversight accidents, incidents and concerns were not fully investigated and actions were not taken in a timely manner to reduce the further risk of harm to people. There were no records to demonstrate what learning had been identified or how this had been shared with staff. For example, we found that people had falls within the service, but there was no analysis of these incidents for patterns and trends. This meant opportunities for learning and the chance to improve the service provided were missed. Staff told us, “There is no guidance on what we do with falls charts and who reviews them or how often they are reviewed”. We received mixed feedback from relatives. One relative told us, “I would say [they] were fully safe; however, now [their] needs have increased, it’s different”.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety even when they were identified as at risk or had incidents which harmed them. We could not see that the service completed a pre-assessment with people and their relatives before they moved into the service, and the new manager was unsure of the normal processes for referrals and admissions. Care plans were in place for people; however, these were inconsistent, and there were discrepancies about whether referrals had been made. We found referrals were not made promptly, which meant people did not receive the most appropriate care and support to meet their needs. We found staff continually raised concerns in daily notes about people’s health, but these had not been reviewed by the registered manager.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We found not all accidents and incidents that resulted in injuries had been reported to the Local Authority or to the Care Quality Commission (CQC). There were Safeguarding and CQC logs in place, which had not been updated between January and October 2025. This meant safeguarding information was not readily available, reported as required by regulation, or accurate. Mental capacity assessments had not been completed in line with the Mental Capacity Act (MCA) 2005, and not all staff had received safeguarding and MCA training.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. Some people had health conditions and support needs that increased their risk of harm. The provider did not ensure adequate risk assessment and management plans were in place for staff to safely manage these conditions. Where people had known risks, the provider/leadership team could not demonstrate they had completed risk assessments or worked collaboratively with relatives to mitigate this risk. We found other people at risk of falls without any assessments in place. The guidance for staff about how to reduce these risks was either not in place, lacked detail, or was not followed. We raised our concerns with the provider, and in response they began to complete reviews of people’s risk assessments.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities, and technology supported the delivery of safe care.People’s medications were kept in their apartments on their kitchen tables. They were not stored safely, following the provider’s own policy. We found Personal Emergency Evacuation Plans (PEEPs) had been updated in October 2025 and were in place for all people. However, the information included was limited and did not accurately reflect people’s abilities and support needs in an emergency. This meant people were at ongoing risk of significant harm in case of an emergency evacuation. The emergency grab bag was not readily available to staff. We raised these concerns with the provider at the time of our visit. The provider had reviewed the PEEPs, but the PEEPs risk overview sheet still held incorrect information and a confusing Red Amber Green (RAG)rating. A RAG rating is a colour-coded system used to visually communicate risk, so people’s needs can be quickly identified. The provider had begun to implement safe storage of medications and had changed the location of the grab bag, so it was accessible.

The provider did not always make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not always work together well to provide safe care that met people’s individual needs. We found not all staff had received the training needed for their roles to be able to support people safely, and staff training had not been reviewed regularly. As a result people were at risk of harm. We saw in the team meeting notes from 7 October 2025; staff having to hoist a person four times and still could not get them sitting right.

People told us the permanent staff were good and caring. One person told us, “They do so much for me and know my needs”. However, people raised concerns about the competency of some agency staff. A person told us, “Agency staff are not very good, some do not speak English well, and they do not understand us, and we do not understand them”. We could not see that the provider had a consistent system of ensuring agency staff were competent, or of introducing agency staff to people that use the service. Relatives told us there was not enough time for care calls, meaning some people had to wait longer for their care. We raised our concerns about training with the provider, and they had begun to review staff training and were organising additional training sessions to address the concerns.

The provider did not always assess or manage the risk of infection. They did not alwaysdetect and control the risk of it spreading or share concerns with appropriate agencies promptly.We received positive feedback from people and their relatives. One person said, “They wash their hands; they wear a mask as I pick up colds or anything going around”. While a relative told us, “They wash their hands, then put gloves on, they always wear gloves”. People were supported to keep their apartments clean by receiving domestic calls if needed. However, we found that during a staff meeting on 7 October 2025, staff were discouraged from telling people who use the service that there had been a COVID outbreak. We could not, however, see that official communication had gone out to people to inform them of this.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. People were not involved in planning. We found people’s care plans did not include information on the medication they were prescribed and included conflicting information on who supported people to take their medication. Folders kept in people’s apartments held lists of medication that were out of date, and some people’s folders did not include any medication lists. This put people at risk of being given the wrong medication or giving it incorrectly not in line with how it may have been prescribed.

We observed medication administration record (MAR) charts where medication had not been signed as received, despite it being part of staff responsibilities and policy. Some medication stock had not been included from the previous month, so the number was not accurate on the MAR. We found one person had run out of their pain relief medication. We raised our concerns with the service. When we returned on 19 November2025, we found the same concerns with the MARs. Medication errors were not managed following the provider’s policy, and one person had missed their antibiotics for two days, meaning assurance systems were not robust to identify errors and take prompt action.